BALTIMORE 鈥� Ask David Ross to describe an average day on the job. He says it doesn鈥檛 exist.
Ross is a violence intervention specialist at the University of Maryland Medical Center. Though he isn鈥檛 a doctor, he鈥檚 been working at the hospital as part of its Violence Prevention Program for close to 10 years. His team works with patients who are victims of violent injuries 鈥� stabbings, gunshots or physical assaults 鈥� and who physicians flag as candidates for the program鈥檚 assistance.
His challenge is to figure out the factors in their lives that put them at risk of violence. The work he does is time-consuming, and the relationships he builds with these patients can last months and even years.
Do you feel safe at home? Do you have health insurance? A high school diploma? A stable job? Having health insurance or a diploma is no guarantee against violence, but Ross and his colleagues ask such questions to help the team connect patients with programs that might improve their lives and insulate them from the violence that put them in the hospital.
鈥淪ome days, it can be emotional. Or it can be gratifying,鈥� Ross said. 鈥淚 spoke to a patient the other day, and he almost had me crying.鈥�
Sometimes that kind of emotion comes from the devastating things patients have seen, whether it鈥檚 the result of a dysfunctional living situation, substance abuse, poverty or other social ills. Other times, it鈥檚 because 鈥測ou thought you made progress 鈥� and then there鈥檚 a setback.鈥�
Maryland is a pioneer in this type of coordinated effort, having launched its anti-violence program in 1998. Now, 鈥� from the Children鈥檚 Hospital of Philadelphia to the University of Rochester Medical Center in New York 鈥� have developed similar initiatives. They follow Maryland鈥檚 鈥渨raparound鈥� approach, which involves following up with patients after they leave the hospital, and providing medical and social support to keep them out of harm鈥檚 way 鈥� by, for example, getting them into drug rehab or education classes for people who have not finished high school. The hospitals are acting on the notion that keeping violent injury from recurring will ultimately reduce their expenses and improve people鈥檚 long-term health. In other words, they increasingly view violence prevention programs as both good medicine and good business.
On this particular day, Ross visited seven hospital patients who were being treated for violent injuries. Ross鈥檚 job isn鈥檛 just to identify the trouble spots in a patient鈥檚 life; it also involves moving with the person through the legal and medical systems, sometimes acting as an advocate. The day before, for instance, he had accompanied a mentally ill client to court to make sure the man鈥檚 condition was understood by聽authorities. On such days, he dresses in a suit instead of his hospital uniform: pink scrubs, an outfit that shows that while he doesn鈥檛 stitch wounds or prescribe pills, he鈥檚 part of a team dedicated to keeping patients healthy.
As experts increasingly view violence as a medical concern, hospitals see it as an opportunity. 鈥淭here鈥檚 been a groundswell of professionals understanding that this is a public health issue,鈥� said Rochelle Dicker, a trauma surgeon and professor at the University of California, San Francisco, who directs the UCSF Medical Center鈥檚 violence prevention program.
And the 2010 federal health law supports that interest. It says nonprofit hospitals have to work harder if they want to maintain their tax-exempt status:聽, they have to formally measure their surrounding community鈥檚 health needs at least every three years and implement a strategy to address them.
To this end, a growing number of hospitals, especially those located in areas with high rates of violent crime, are partnering with local organizations to try to reduce neighborhood violence, said Jonathan Purtle, an assistant professor at Drexel University who researches hospitals and violence prevention.
The Department of Justice has been supportive, too. , it recommended that hospitals become more involved in violence prevention, through counseling patients directly or connecting them with education, gang diversion programs, substance abuse treatment and other social services.
Research shows that, if someone comes in suffering from a gunshot or stab wound and then, after leaving the hospital, returns to the same environment, there are good odds they will be back in the emergency department. In addition, trends and anecdotal evidence suggest people at higher risk for violent injury are likely to face issues such as domestic violence, mental illness or substance abuse. They also often deal with other stressors, like poverty or bad housing. These challenges can result in health problems including lead poisoning and poor nutrition, which the hospital can work to address. Even if they can鈥檛 change, for instance, a neighborhood鈥檚 crime rate or drug culture, they can help someone get into rehab or find somewhere new to live.
Much of the growth in such hospital interventions has happened in the past five years, Dicker said.
鈥淚t鈥檚 becoming a more established understanding that this kind of violence is preventable,鈥� said Rebecca Cunningham, an emergency medicine professor at the University of Michigan and associate director of its youth violence prevention center. 鈥淎nd we can have programs that can prevent it, and the hospital and emergency department are really critical locations for this.鈥�
Michigan鈥檚 center doesn鈥檛 do that same level of outreach and case management as Maryland鈥檚. All patients between the ages of 14 and 20 and from neighborhoods where violence is more prevalent are approached for a counseling session 鈥� what Cunningham called a 鈥減reventive鈥� intervention.
So far, there isn鈥檛 much research measuring these programs鈥� effectiveness. But the findings available show promise. UCSF found that people who had come to the hospital with a gunshot or stab wound and then participated in the intervention program were far less likely to get injured again after leaving. The number of patients returning with another violent injury dropped from 16 percent to 4.5 percent. , researchers estimated that program would save the hospital half a million dollars annually.
That鈥檚 crucial. 鈥淚t鈥檚 very important to be able to talk about cost effectiveness鈥� as hospitals look to curb unnecessary expenses, Dicker said.
The University of Maryland鈥榮 statistics are similarly encouraging. Research found victims of violent injury who went through the program were 83 percent less likely to return because of another violent event when compared with those who didn鈥檛 participate, said Tara Reed Carlson, who directs the university鈥檚 Center for Injury Prevention and Policy. Those who had participated in the program were more likely to have a job and less likely to be involved in criminal activity.
Ross said the work he does 鈥� and the change he sees 鈥� underscores the value of intensive outreach. The before-and-after contrast is striking. 鈥淚鈥檓 talking about young guys who haven鈥檛 had any guidance,鈥� he said. 鈥淭hat鈥檚 rewarding.鈥�
Often, he said, patients stop by to visit, years after they鈥檝e gone through the program. They share new successes, like buying a home or getting married.
鈥淚t makes you feel good,鈥� he said. 鈥淵ou鈥檙e doing something that鈥檚 needed.鈥�